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R E S TO R AT I V E

Bulk-Fill Composites
for Class II Restorations
Nathaniel Lawson, DMD, PhD; and
Augusto Robles, DDS, MS
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Restorations CDEWorld eBooks and Bulk-Fill Composites for Class II

Nathaniel Lawson, DMD, PhD
Augusto Robles, DDS, MS
ABOUT THE AUTHORS
Nathaniel Lawson, DMD, PhD
Nathaniel Lawson, DMD, PhD, is an assistant
professor in the division of biomaterials at
the University of Alabama at Birmingham
(UAB). He started his education as a
biomedical engineering student at Tulane
University. He completed his DMD at the
UAB School of Dentistry and his MS and
PhD in the department of miomedical engineering at UAB. Following
graduation, he worked in private practice for 1.5 years in Alabama
and Illinois. Dr. Lawson is passionate about testing new materials and
techniques in the laboratory. His main research focus involves testing
the strength, color, wear, roughness and bond strength of ceramics,
composites, cements, impression materials, and adhesives.
Restorations are published by Dental Learning Systems.
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WARNING: Reading an article in CDEWorld and Bulk-Fill
Composites for Class II Restorations does not necessarily
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your practice. Dental Learning Systems, LLC expects its read-
ers to rely on their judgment regarding their clinical expertise
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trying to implement any new procedure.
Printed in the U.S.A.

ABOUT THE AUTHORS CEO

Daniel W. Perkins
Augusto Robles, DDS, MS
Augusto Robles, DDS, is an Assistant PRESIDENT
D ental L earning S ystems , llc
Karen A. Auiler P.O. Box 510
Professor and Director of Operative
Newtown, PA 18940
Dentistry at the University of Alabama, PARTNER
Anthony A. Angelini Phone - 267-291-1150
Birmingham, School of Dentistry. A mem-
ber of the American Academy of Cosmetic
Dentistry, he maintains a private practice in
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 2 CDE CREDITS

COMPOSITES Nathaniel Lawson, DMD, PhD | Augusto Robles, DDS, MS

2 CDE
CREDITS

Bulk-Fill Composites for

Class II Restorations
Examining shrinkage stress and depth of cure in
this new material class

The layering technique has been advocated for posterior composites to reduce polymerization
ABSTRACT

shrinkage and allow adequate depth of cure. Recently, bulk-fill composites have been introduced
that allow the practitioner to place composites in increments of 4 mm. Initial testing of these
materials has determined that bulk-fill composites can obtain a depth of cure and shrinkage stress
at 4 mm comparable with a conventional composite with a 2-mm increment. Bulk-fill composites
were first introduced in a flowable consistency and have since been formulated with a high-viscosity
universal consistency. Some flowable materials do not exhibit sufficient wear resistance and must
be covered with a more highly filled composite. The technique for placing these materials is slightly
different than for conventional composites, as the layers of composites are not condensed against
the matrix, and therefore, a contoured matrix, ring, and sufficient wedging are recommended.
Flowable bulk-fill materials are well-suited for Class II boxes and build-ups around posts.

LEARNING OBJECTIVES
• Explain the importance of shrinkage
stress and depth of cure in the bulk-fill
technique.
• Understand how bulk-fill composites
reduce shrinkage stress and increase
depth of cure.
• Describe the types, clinical applications,
and limitations of bulk-fill composites.
T
he long-taught practice for composite
restorations has been to place com-
posite material incrementally in 2-mm
layers. Part of the theory behind this teaching
was that it would reduce the total amount of
polymerization shrinkage of the composite. As
one layer of composite is placed and cured, all
surfaces of that composite layer not bonded to
tooth structure could contract freely. In this way,
stress relief could be achieved at each layer of
cured composite, as opposed to a single cured
layer with a bulk-filling technique. However,
some researchers have questioned the benefits of
using incremental filling to reduce the clinical ef-
fects of composite shrinkage.1 A more substantial

VOLUME 2 • NUMBER 30 CDEWorld.com 1

 COMPOSITES
claim for the 2-mm composite increment is the
ability of a curing light to effectively polymerize
a composite to this depth. Both polymerization
shrinkage and depth of cure are important clinical
parameters. Excessive polymerization shrinkage
could lead to open margins, microleakage, and
postoperative sensitivity or cuspal deflection
and enamel fracture. Inadequate depth of cure
2
could leave composite at apical margins soft and
susceptible to wear, dissolution, or fracture. 3
The impetus for bulk-filling composites is a
desire to reduce the time required for compos-
ite placement and to eliminate the possibility
of voids between composite layers. The time
savings allowed by placing a single layer of
composite can be appreciated by both the
dentist and patient. In addition, an unwanted
side effect of the incremental placement
technique is the introduction of voids between
composite layers. For universal handling com-
posites, the stickiness of the composite to the
placement instrument can make it difficult to
completely adapt the new layer of composite
to the previous layer. When placing additional
layers of flowable composite, air can become
trapped between layers. Internal voids may be
innocuous in some clinical cases; however, in
stress-bearing areas, a void may act as a site of
stress concentration and eventual fracture.4
Voids or gaps present on the external surface of
a composite restoration may be more prone to
staining.
How Bulk-Fill Composites Work
2 CDEWorld.com
In response to the clinical demand for materi-
als compatible with bulk-filled placement, a
new class of dental composites has been devel-
oped. In general, bulk-fill composite materials
are characterized by lower shrinkage stress
and a higher depth of cure than conventional
composites. Shrinkage stress is defined as the
amount of force per area exerted on the walls
of a cavity preparation by a composite as it po-
lymerizes. Volumetric shrinkage, on the other
hand, is the difference in volume between an
uncured and cured specimen of composite.
Shrinkage stress is more clinically important
than volumetric shrinkage because a material
that shrinks substantially when cured on a
countertop may not exert large forces when
cured inside a bonded restoration.5
Methods that manufacturers may employ
to produce composites that do not exert
high stress during polymerization include
increasing “flexibility” of polymer networks
in the composite resin; incorporating “flex-
ible” fillers in the composite; and slowing the
polymerization reaction to allow polymers
time to disperse prior to crosslinking.6-8 Many
commercially available bulk-fill composites
incorporate one or more of these techniques
to reduce polymerization shrinkage. Several
research studies have compared polymeriza-
tion shrinkage of conventional composites
and bulk-fill composites. Broadly, bulk-fill
flowables have less polymerization shrinkage
stress than conventional flowables, and high-
viscosity bulk-fill composites demonstrate
DECEMBER 2015
 2 CDE CREDITS

polymerization stress similar to or less than

comparable conventional composites.7,9-11

Depth of Cure
Bulk-fill materials are marketed with claims
that they have 4 mm of curing depth. Depth of
cure is commonly measured by measuring the
hardness or the degree of double-bond conver-
sion at the surface of a composite exposed FIGURE 1. Spectral output of LED and polywave curing
lights and maximum absorption of different photoinitiators.
to a curing light and comparing it with the
degree of conversion at various depths of the
restoration. Several studies have determined
that bulk-fill composites have a degree of
conversion (indicating adequate crosslinking)
of at least 80% of their surface value at 4-mm
depths.11-13 Other studies have determined
that hardness values at 4 mm were at least
80% of the surface hardness for most bulk-fill
materials.7,14-17 Some studies suggested that not FIGURE 2. Preparation of tooth No. 31

all high-viscosity bulk-fill composites could

achieve acceptable hardness all the way to
4 mm.13,15,17 All bulk-fill composites showed
higher depths of cure than conventional
composites used as a control.7,11,15-17

Manufacturers have achieved this depth of

cure by modifying the translucency of the
composite and including more effective light FIGURE 3. Restoration of tooth No. 31.

initiators. When a composite is light cured
from the occlusal direction, light energy from
the curing light must be transmitted through
the bulk of the composite without being
absorbed or deflected before reaching the
bottom of the restoration. By adjusting the
translucency of the composite or matching
the refractive index of the filler and the resin,
light can travel through an increased depth of
a bulk-filled composite.18,19 A side effect of this
modification is that several of these materials
appear more visually translucent than tooth
structure.

VOLUME 2 • NUMBER 30 CDEWorld.com 3

 COMPOSITES

The other method that manufacturers have

used to increase depth of cure is by incorporat-
ing more efficient and robust light initiators.
Most dental composites polymerize by activat-
ing the photoinitiator camphorquinone (CQ).
When the energy from a curing light excites
CQ, it stimulates an amine co-initiator to
release a free radical and initiate resin polym-
FIGURE 4. Preparation of tooth No. 19 with 4-mm distal box.
erization. Ivocerin®, a new germanium-based
photoinitiator patented by Ivoclar Vivadent
(www.ivoclarvivadent.us), does not require
a co-initiator and requires less energy from
a curing light to produce crosslinking of the
resin composite.8,20 Therefore, composite at
the bottom of a 4-mm layer requires less light
to achieve sufficient mechanical and physical
properties.
FIGURE 5. Placement of composite into tooth No. 19.

In addition, manufacturers have added blends

of photoinitiators that are activated at differ-
ent wavelengths of light to optimize the energy
from a curing light. CQ is maximally stimulat-
ed at 468 nm. Ivocerin has a maximum absorp-
tion of 410 nm. The photoinitiators phenyl-
propanedione (PPD) and Lucirin® TPO (BASF,
www.basf.com) absorb a lower wavelength of FIGURE 6. Restoration of tooth No. 19.
light (385-400 nm) and have been used in light
and translucent shades of composite because
they do not exhibit the yellowing associated
with CQ.

Effective Light Curing

The range of maximum of absorption of differ-
ent photoinitiators has clinicians concerned FIGURE 7. Post placed in tooth No. 13.
that their curing lights do not have

4 CDEWorld.com DECEMBER 2015

 2 CDE CREDITS

the spectral output to effectively polymerize

these composites. For reference, a typical LED
curing light has a spectral output of utilizable
wavelength ranging from 430 to 480 nm. New
polywave or multi-wavelength LEDs have
expanded spectral outputs. These new lights
include VALO® by Ultradent (www.ultradent.
com) with a range of 395 to 480 nm and the
FIGURE 8. First layer of core build-up in tooth No. 13 placed.
Bluephase® 20i by Ivoclar Vivadent with a
range of 385 to 515 nm. Testing by the author,
however, has revealed that Tetric EvoCeram®
Bulk Fill with Ivocerin (Ivoclar Vivadent)
could be effectively cured to 4 mm with both
a traditional and polyphase LED curing light
(Figure 1). Because Tetric EvoCeram Bulk Fill
is the only bulk-fill composite marketed with
FIGURE 9. Core build-up on tooth No. 13 completed.
a new photoinitiator, the concern of composite
and light compatibility may not be of clinical of energy, lights with lower outputs must be
relevance with current materials. compensated by using longer exposure time.h

Clinicians should be concerned, however, Types of Bulk-Fill Composites

about the power output (also called irradiance)
of their curing lights. The depth of cure of a
bulk-fill composite measured in laboratory
testing is typically determined with relatively
new lights with power outputs greater than
600 mW/cm2. A recent study has shown that
dental curing lights measured at 200 private
practices had low outputs (200 mW/cm2 to
400 mW/cm2) and were covered with compos-
ite residue.21 Clinicians should monitor the
output of their curing lights and keep their
light tips clean with protective sleeves or
acetone-based cleaners. Because every resin
composite requires a minimum amount
Many manufacturers have entered the market
with bulk-fill composites. SureFil® SDR® by
DENTSPLY Caulk (www.caulk.com) was one
of the first materials advertised for use with a
4-mm layer. This flowable composite is char-
acterized by very low shrinkage stress and
high translucency. Modifying the polymeriza-
tion kinetics and allowing the material to flow
during polymerization leads to low shrinkage
stress. It must by “capped” with a more wear-
resistant composite and is used primarily
as a base in deep areas of preparations and
proximal boxes. Filtek™ Bulk Fill Flowable
was introduced by 3M ESPE (www.3mespe.

VOLUME 2 • NUMBER 30 CDEWorld.com 5

 COMPOSITES
com), followed shortly by the more highly
filled Filtek™ Bulk Fill Posterior Restorative.
The novel components of these materials are
two monomers. One monomer can fragment in
response to shrinkage stresses and rebond in
a more relaxed position, and the other reduces
the density of crosslinking.8
Ivoclar Vivadent released its highly filled
material Tetric EvoCeram® Bulk Fill and later
a flowable version, Tetric EvoFlow Bulk Fill.
These materials contain the photoinitiator
Ivocerin as well as stress-relieving “flexible”
filler particles.6 Kerr’s SonicFill™ (www.
kerrdental.com) utilizes sonic energy (vibra-
tions within the audible frequency) to reduce
the viscosity of a highly filled material and
allow it to flow into a preparation. The sonic
energy is supplied by a specific handpiece that
attaches to an air hookup and is dispensed by
pressing on a rheostat. After dispensing, the
material returns to a sculptable state, allowing
the clinician to contour the restoration. The
high concentration of filler particles (83.5
wt%) reduces polymerization shrinkage of the
composite as the resin, not the fillers, contract
upon polymerization. The manufacturer does
not explain how the increased depth of cure
is obtained. Other bulk-fill composite materi-
als include QuiXX® (DENTSPLY), Beautifil®
(Shofu, www.shofu.com), Venus® Bulk Fill
(Heraeus Kulzer, www.heraeus-kulzer.com),
HyperFIL™ (Parkell Inc., www.parkell.com),
and X-tra Base (Voco, www.voco.com).
6 CDEWorld.com
Techniques and Applications
The placement techniques for bulk-fill com-
posites vary for flowable and higher viscosity
materials. Bulk-fill flowable composites are
primarily used for deep bases and interproxi-
mal boxes under conventional composites.
Interproximal boxes can easily reach depths
beyond 4 mm, and therefore at least two incre-
ments of composite are needed. To reinforce
this point, it is important to note that bulk-fill
does not mean one increment up to the oc-
clusal surface. Instead, it implies increments
up to 4 mm in depth. Even for shallow prepara-
tions of 4 mm or less, flowable bulk-fill com-
posites are not indicated for the final occlusal
layer. The two main reasons these materials
are not placed up to the occlusal surface of a
restoration are their low wear resistance and
high translucency.
A study of several flowable bulk-fill compos-
ites showed that all flowables had signifi-
cantly more wear than the control (Z100™, 3M
ESPE); more wear was seen for SureFil SDR
(0.04 mm3) than Venus Bulk Fill (0.024 mm3)
or Filtek Bulk Fill (0.012 mm3). 23 In addition,
flowable bulk-fill composites tend to have a
very high translucency that prevents them
from blending with natural tooth structure.
For this reason, manufacturers recommend
covering or “capping” these materials with a
conventional posterior composite.
Higher viscosity bulk-fill composites can be
used up to the occlusal surface, however. Two
DECEMBER 2015

clinical cases using the bulk-fill composites
Tetric EvoCeram Bulk Fill and SonicFill
are presented in Figure 2 through Figure 6.
Limitations when placing a high-viscosity
bulk-fill composite include difficulty of con-
densing and esthetic restraints. Condensing a
high-viscosity resin composite ensures ad-
equate adaptation to the tooth preparation and
sufficient interproximal contacts. Condensing
4 mm of composite is more difficult than
condensing 2 mm. To ensure adequate inter-
proximal contacts, a sectional or circumferen-
tial matrix with an inciso-gingival curvature
can be used to obtain a tight area of contact
gingival to the marginal ridge. A ring should
be used to help separate the teeth and improve
the tightness of the contact area.
An esthetic limitation of bulk-fill composites
is that most materials are available in a small
selection of shades. In addition, some of these
materials have slightly higher translucency
than conventional posterior composites. The
esthetics achieved by these composites should
be sufficient for posterior restorations for
most patients.
Another possible clinical application of bulk-
fill composites is for use as a core build-up ma-
terial. A clinical case demonstrating this tech-
nique is presented in Figure 7 through Figure
9. Build-ups are often placed into large, deep
preparations with pins or a post. Therefore,
important characteristics to consider for these
materials are their shrinkage stress, depth of
VOLUME 2 • NUMBER 30
2 CDE CREDITS
cure, flow, and toughness/strength. Flowable
bulk-fill composites are desirable materials to
use for build-ups because they have appropri-
ate flow to adapt to a post or pin, low shrinkage
stress, and high depth of cure, allowing them
to be placed in bulk with the strength and
toughness of a resin composite.
Conclusions
Bulk-fill composites are a new class of mate-
rial with scientific evidence for claims of low
polymerization shrinkage and 4-mm depths
of cure. The appearance, handling, and me-
chanical properties of bulk-fill composites
vary between flowable and high-viscosity
materials. In general, flowable materials have
a deeper depth of cure; however, high-viscosity
materials have better wear resistance and
less transparency. The handling and esthetic
limitations of these materials may not be suf-
ficient for use in anterior restorations; how-
ever, bulk-fill materials are a good solution for
efficient posterior restorations and possibly
core build-ups.
References
1. Versluis A, Douglas WH, Cross M, Sakaguchi
RL. Does an incremental filling technique
reduce polymerization shrinkage stresses? J
Dent Res. 1996;75(3):871-878.
2. Giachetti L, Russo DS, Bambi C, Grandini
R. A review of polymerization shrinkage stress:
current techniques for posterior direct resin
restorations. J Contemp Dent Pract. 2006;7(4).
3. Shortall AC. Depth of cure of
CDEWorld.com 7
 COMPOSITES
radiation-activated composite restoratives-
-influence of shade and opacity. J Oral Rehabil.
1995;22(5):337-342.
4. Purk JH, Dusevich V, Glaros A, Eick JD.
Adhesive analysis of voids in Class II composite
resin restorations at the axial and gingival cav-
ity walls restored under in vivo versus in vitro
conditions. Dent Mater. 2007;23(7):871-877.
5. Kappler O, Weinmann W, Thalacker C, et al.
Correlation of strain, shrinkage and E-modulus
of modern filling composites [abstract 56].
Presented at: IADR General Session; April 1,
2009; Miami, FL.
6. Can Say E, Özel E, Yurdagüven H, Soyman M.
Three-year clinical evaluation of a two-step self-
etch adhesive with or without selective enamel
etching in non-carious cervical sclerotic lesions.
Clin Oral Investig. 2014;18(5):1427-1433.
7. El-Damanhoury H, Platt J. Polymerization
shrinkage stress kinetics and related proper-
ties of bulk-fill resin composites. Oper Dent.
2014;39(4):374-382.
8. Ivoclar Vivadent Report No. 19. 2013;19:1-42.
9. Jang JH, Park SH, Hwang IN. Polymerization
shrinkage and depth of cure of bulk-fill resin
composites and highly filled flowable resin.
Oper Dent. 2015;40(2):172-180.
10. Kim RJ, Kim YJ, Choi NS, Lee IB.
Polymerization shrinkage, modulus, and shrink-
age stress related to tooth-restoration interfa-
cial debonding in bulk-fill composites. J Dent.
2015;43(4):430-439.
11. Marovic D, Tauböck TT, Attin T, et al.
Monomer conversion and shrinkage force kinet-
ics of low-viscosity bulk-fill resin composites.
8 CDEWorld.com
Acta Odontol Scand. 2015;73(6):474-480.
12. Czasch P, Ilie N. In vitro comparison of
mechanical properties and degree of cure
of bulk fill composites. Clin Oral Investig.
2013;17(1):227-235.
13.Tarle Z, Attin T, Marovic D, et al. Influence
of irradiation time on subsurface degree of
conversion and microhardness of high-viscosity
bulk-fill resin composites. Clin Oral Investig.
2015;19(4):831-840.
14. Alrahlah A, Silikas N, Watts DC. Post-cure
depth of cure of bulk fill dental resin-compos-
ites. Dent Mater. 2014;30(2):149-154.
15. Benetti AR, Havndrup-Pedersen C, Honoré
D, et al. Bulk-fill resin composites: polymeriza-
tion contraction, depth of cure, and gap forma-
tion. Oper Dent. 2015;40(2):190-200.
16. Do T, Church B, Veríssimo C, et al.
Cuspal flexure, depth-of-cure, and bond
integrity of bulk-fill composites. Pediatr Dent.
2014;36(7):468-473.
17. Flury S, Peutzfeldt A, Lussi A. Influence of
increment thickness on microhardness and
dentin bond strength of bulk fill resin compos-
ites. Dent Mater. 2014;30(10):1104-1112.
18. Bucuta S, Ilie N. Light transmittance and
micro-mechanical properties of bulk fill vs.
conventional resin based composites. Clin Oral
Investig. 2014;18(8):1991-2000.
19. Fujita K, Nishiyama N, Nemoto K, et al.
Effect of base monomer’s refractive index on
curing depth and polymerization conversion
of photo-cured resin composites. Dent Mater J.
2005;24(3):403-408.
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 2 CDE CREDITS

20. Moszner N, Fischer UK, Ganster B, et al.

Benzoyl germanium derivatives as novel visible
light photoinitiators for dental materials. Dent
Mater. 2008;24(7):901-907.
21. Hegde V, Jadhav S, Aher GB. A clinical
survey of the output intensity of 200 light cur-
ing units in dental offices across Maharashtra. J
Conserv Dent. 2009;12(3):105-108.
22. Roulet JF, Price R. Light curing—guidelines
for practitioners—a consensus statement from
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wear of eight bulk placed and cured composites
[abstract 2441]. Presented at: IADR General
Session; March 22, 2013; Seattle, WA.

Editor’s Note
This article was originally published in
Inside Dentistry. Copyright © 2015 to AEGIS
Publications, LLC. All rights reserved. Used
with permission of the publishers.

VOLUME 2 • NUMBER 30 CDEWorld.com 9

CDE Quiz 2 CDE Credits 2 CDE CREDITS

heraeus.cdeworld.com/courses/20046

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Bulk-Fill Composites for Class II TO TAKE THE QUIZ, VISIT:

Restorations
CDEWORLD.COM/EBOOKS/CE/30
Nathaniel Lawson, DMD, PhD
Augusto Robles, DDS, MS

1. Excessive polymerization shrinkage could lead 6. Which is the maximum absorbance of the
to: photoinitiator Ivocerin?
a. open margins. a. 400 nm
b. microleakage. b. 410 nm
c. postoperative sensitivity. c. 436 nm
d. All of the above d. 486 nm

2. What is an unwanted side effect of the 7. Which is the spectral output of a typical LED
incremental placement technique? curing light?
a. Increased shrinkage. a. 430 to 480 nm
b. Loss of occlusal anatomy. b. 395 to 480 nm
c. Voidsy. c. 385 to 515 nm
d. Postoperative sensitivity. d. 300 to 500 nm

3. Shrinkage stress is defined as: 8. Why is it recommended to “cap” flowable

a. the amount of force per area exerted on bulk-fill composites?
preparation walls as a composite is polymerized. a. Insufficient depth of cure
b. the difference in volume between cured and b. Low polishability
uncured composite. c. Low wear resistance
c. the difference between surface hardness and d. Insufficient handling propertie
hardness at a 4-mm depth.
d. the ratio of fillers to polymers in a compos- 9. What are esthetic limitations of bulk-fill
ite. composites?
a. Reduced shade selection
4. In local anesthetic formulations, epinephrine is b. Relatively high translucency
available at what concentration? c. Low polishability
a. 2 mm d. A and B
b. 3 mm
c. 4 mm 10. What properties of flowable bulk-fill
d. 5 mm composites make them desirable for core
build-ups?
5. How have manufacturers increased the depth a. High flow for adaptation to post or pin
of cure of bulk fill composites? b. Low shrinkage stress
a. Adding light-transmitting fibers c. High depth of cure
b. Increasing their translucency d. All of the above
c. Including new photoinitiators
d. B and C

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